Fillable Record Of Parental Request For Re-Evaluation printable pdf download

SOUTH BEND COMMUNITY SCHOOL CORPORATION

SPECIAL EDUCATION DEPARTMENT

RECORD OF PARENTAL REQUEST FOR RE-EVALUATION

Student’s name: _________________________________ DOB: __________________________

School: ____________________ Grade: ___________

Teacher: ________________________

ID# _______________________ STN#: ____________________________________________

Parent’s name: __________________________________________________________________

Address:_______________________________________________________________________

__________________________________________________________________

Certified Personnel* who received Request for Evaluation: _____________________________

How Request was received: _______________________________________________________

Date of Request: _________________________

PARENT

If the parent makes the Request for an evaluation in person at the school, please have the parent

sign below.

I am requesting a re-evaluation for my child, ____________________, DOB: ________.

Place your initials on the appropriate option below:

_____ *I suspect that my child may have a different or additional eligibility for special

education services. I suspect the disability(ies) of: ______________________________.

_____ *Additional information is needed to inform the Case Conference Committee of my

child’s special education needs. Describe specifically:____________________________

_______________________________________________________________________

_____ There is a need to re-establish my child’s eligibility to determine if he/she continues to be

eligible for special education services. I understand that my child will be re-evaluated

prior to the next Annual Case Conference.

*I understand that within 10 school days, I will receive Written Notice informing me

whether the school proposes or refuses to evaluate my child. At that time, if the school

makes a recommendation to proceed with the evaluation, I will be asked to provide

written consent for this evaluation.

Parent Signature: ______________________________________

Date: ______________

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If the parent does not make the Request in person at the school, the certified personnel

who received the Request must document at the top of this page, his/her name, the date of

the request, and the type of re-evaluation requested. It is not necessary to have the

parent sign this form.

THIS COMPLETED FORM MUST BE IMMEDIATELY FORWARDED TO THE

TEACHER OF RECORD who will distribute the Classroom Teacher Report and distribute

copies of this page to those on the CC list.

Date distributed to Teacher: ______________________________

Record Of Parental Request For Re-Evaluation